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The heterogeneity of the core symptoms of posttraumatic stress disorder (PTSD), high rates of comorbid mental and physical health conditions, and substantial impact of the disorder on functioning and well‐being contribute to complex clinical presentations that can be challenging to treat. Despite these challenges, there are excellent manualized treatments for PTSD with significant empirical support. Although the success of frontline treatments for PTSD is evident, there remains room for improvement as indicated by suboptimal response and attrition rates. To address challenges to optimal therapy outcomes (COTOs), researchers have conducted numerous clinical trials designed to (a) enhance the core structure of treatment protocols to increase flexibility or (b) expand the protocols to address comorbid conditions that inhibit recovery. However, it is implausible to ever conduct the number of enhancement and expansion clinical trials necessary to test manual modifications for the universe of possible COTOs. This conceptual review describes the concept of a personalized model of therapy that leverages a case formulation approach to implementing an evidence‐based treatment for PTSD. This personalized approach provides guidance for the clinician in assessing the patient's COTOs, monitoring them throughout treatment, and relying on the patient's idiosyncratic data to inform treatment decisions, including how and when to diverge from treatment when clinically indicated and ensuring a clear path to return to trauma‐focused work when the COTO is stabilized. This personalized, case formulation approach to treating PTSD provides guidance for adopting a more flexible approach to treating clinically complex patients while ensuring fidelity to the protocol. [ABSTRACT FROM AUTHOR]

Purpose: There is limited research exploring the usefulness of generic preference-based quality of life (GPQoL) measures used to facilitate economic evaluation in the context of posttraumatic stress disorder (PTSD). The aim of the current study was to explore the validity and responsiveness of a common GPQoL measure (Assessment of Quality of Life 8 Dimension [AQoL-8D]) in relation to a PTSD condition-specific outcome measure (Posttraumatic Stress Disorder Checklist for the DSM-5 [PCL-5]). Method: This aim was investigated in a sample of individuals (N = 147) who received trauma-focused cognitive-behavioural therapies for posttraumatic stress disorder. Convergent validity was investigated using spearman's correlations, and the level of agreement was investigated using Bland–Altman plots. Responsiveness was investigated by exploring the standardised response means (SRM) from pre-post-treatment across the two measures, which allow the comparison of the magnitude of change between the measures over time. Results: Correlations between the AQoL-8D (dimensions, utility and summary total scores) and the PCL-5 total score ranged from small to large and agreement between the measures was considered moderate to good. While SRMs were large for the AQoL-8D and PCL-5 total scores, the SRM for the PCL-5 was nearly double that of the AQoL-8D. Conclusion: Our findings demonstrate that the AQoL-8D has good construct validity but present preliminary evidence that economic evaluations using only GPQoL measures may not fully capture the effectiveness of PTSD treatments. [ABSTRACT FROM AUTHOR]

We undertook a systematic review to assess the efficacy of exposure-based writing therapies (WTs) for trauma-exposed adults with subthreshold or clinical levels of posttraumatic stress disorder. Four databases (PsycINFO, Medline, Wiley Online, PILOTS) were searched for randomized controlled trials (RCTs) of exposure-based WTs. A total of 13 RCTs that reported on results from 17 WT versus control comparisons were included. The primary outcomes were posttraumatic stress symptom severity at posttreatment and/or clinical response. An overall unclear or high risk of bias was identified in 84.6% of studies. In comparison to both waitlist k = 3, Hedges' g = -0.97, 95% CI [-1.20, -0.73], and placebo writing conditions, k = 9, Hedges' g = -0.48, 95% CI [-0.87, -0.08], WTs were more beneficial to participants. There was no evidence of a difference between WTs that were longer in duration compared to other psychotherapy, k = 2; pooled OR = 1.42; 95% CI [0.83, 2.43]. These findings indicate that exposure-based WTs are effective when compared to waitlist and placebo writing control conditions. The evidence needs to be considered in the context of the modest number of studies conducted to date, the high methodological heterogeneity between the studies, and the high or unclear risk of bias across many studies. Further research is needed to increase the evidence base regarding the efficacy of WTs for posttraumatic stress. Future research should also measure the mediators and predictors of outcomes to further develop protocols and understand which variants of WTs work for different populations or individuals. [ABSTRACT FROM AUTHOR]

Objective: The efficacy of mindfulness‐based interventions for post‐traumatic stress disorder has not been demonstrated clearly nor have processes of change been examined extensively in the context of post‐traumatic stress. Decreases in trauma‐related rumination is one possible mechanism underlying the positive effect of mindfulness on reducing post‐trauma symptomatology. The present study investigated whether brief mindfulness training reduced post‐traumatic intrusions, testing the mediating role of trauma‐related rumination. Method: Sixty female university students viewed a film clip depicting scenes of physical and sexual violence. They then listened to a short audio of either a mindfulness or relaxation exercise and were instructed to use the respective techniques to manage film‐related rumination in‐session and over the following week. Results: The mindfulness induction decreased vividness of intrusions, but not intrusion frequency or associated distress, nor post‐traumatic stress symptoms or film‐related rumination. No mediation of film‐related rumination was found. Conclusions: Preliminary evidence was found for the effect of mindfulness training on reducing vividness of trauma intrusions, but not intrusion frequency or associated distress. However, the current study failed to observe increases in mindfulness following brief training. Despite this, trait mindfulness predicted lower levels of post‐traumatic stress symptoms. Future research should examine whether trauma‐related rumination constitutes a process of change using more intensive training of mindfulness‐based interventions for post‐traumatic stress disorder. Theoretical and clinical implications are discussed. [ABSTRACT FROM AUTHOR]

Trauma-related rumination is considered one cognitive process that underlies the maintenance of posttraumatic stress. However experimental findings for the effect of trauma-related rumination have been inconclusive and a moderating role of trait rumination has been speculated. Further, existing depression may also interact with traumarelated rumination to increase posttraumatic stress symptoms. The roles of trauma-related rumination, trait rumination and existing depression were therefore investigated. Healthy female participants watched an analogue trauma film and completed either film-related rumination or control inductions involving a distraction and free-thinking task in the first and second experiments, respectively. Participants' frequency of film-related intrusions and associated distress levels were assessed within the initial experimental session, over 1-week after the film and at 1-week follow-up. Induced rumination resulted in greater intrusion-related distress in the second experiment. However no consistent moderations of trait rumination and existing depression were found. Theoretical and clinical implications of findings are discussed. [ABSTRACT FROM AUTHOR]

Although both social support and cognitive appraisals are strong predictors of children's posttraumatic adjustment, understanding of the interplay between these factors is limited. We assessed whether cognitive appraisals mediated the relationship between social support and symptom development, as predicted by cognitive models of posttraumatic stress disorder (PTSD). Ninety seven children (Mean age = 12.08 years) were assessed at one month and six months following a single incident trauma. We administered self-report measures of cognitive appraisals, social support, and a diagnostic interview for PTSD. Results indicated that cognitive appraisals at one month post-trauma mediated the relationship between social support at one month post-trauma, and PTSD severity at follow-up. Differences in this relationship were observed between child-reported social support and parent-rated ability to provide support. Firm evidence was provided for the application of cognitive models of PTSD to children. [ABSTRACT FROM AUTHOR]

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The psychometric properties of the Child PTSD Symptom Scale (CPSS) were examined in 2 samples. Sample 1 (N = 185, ages 6-17 years) consisted of children recruited from hospitals after accidental injury, assault, and road traffic trauma, and assessed 6 months posttrauma. Sample 2 (N = 68, ages 6-17 years) comprised treatment-seeking children who had experienced diverse traumas. In both samples psychometric properties were generally good to very good (internal reliability for total CPSS scores = .83 and .90, respectively). The point-biserial correlation of the CPSS with posttraumatic stress disorder (PTSD) diagnosis derived from structured clinical interview was .51, and children diagnosed with PTSD reported significantly higher symptoms than non-PTSD children. The CPSS demonstrated applicability to be used as a diagnostic measure, demonstrating sensitivity of 84% and specificity of 72%. The performance of the CPSS Symptom Severity Scale to accurately identify PTSD at varying cutoffs is reported in both samples, with a score of 16 or above suggested as a revised cutoff. [ABSTRACT FROM AUTHOR]

The efficacy of a cognitive-behavioral treatment program for individuals with comorbid posttraumatic stress disorder (PTSD) and major depression (MDD) was examined. In an uncontrolled pre- and posttreatment study, participants attended 12-16 weeks of manualized therapy incorporating behavioral activation for depression in early sessions and exposure therapy and cognitive restructuring for PTSD in later sessions. Fourteen participants (of 20) completed treatment. Results indicated a significant decrease in PTSD and depression severity between pre- and midtreatment assessments; PTSD decreased further from mid- to posttreatment. Treatment gains were maintained at 3-month follow-up; 60% of participants no longer met PTSD criteria at 3-month follow-up, and 70% no longer met MDD criteria. The clinical implications of this phased approach to treat PTSD and depression comorbidity are discussed. [ABSTRACT FROM AUTHOR]

Background: Accidental injury represents the most common type of traumatic event to which a child or adolescent may be exposed, with a significant number of these children going on to experience posttraumatic stress disorder (PTSD). However, very little research has examined potential interventions for the treatment of PTSD in these children. The present trial aims to evaluate and compare child- and family-focused versions of a cognitive-behavioural early intervention for PTSD following accidental injury. Methods/Design: The principal clinical question under investigation is the efficacy of an early, trauma-focused cognitive-behavioural intervention for the treatment of PTSD in children following accidental injury. Specifically, we compare the efficacy of two active treatments (child-focused and family-focused CBT) and a waitlist control (no therapy) to determine which is associated with greater reductions in psychological and health-related outcome measures over time. The primary outcome will be a reduction in trauma symptoms on a diagnostic interview in the active treatments compared to the waitlist control and greater reductions in the family-compared to the child-focused condition. In doing so, this project will also trial a method of stepped screening and assessment to determine those children requiring early intervention for PTSD following accidental injury. Discussion: The present trial will be one of the first controlled trials to examine a trauma-focused CBT, early intervention for children experiencing PTSD following accidental injury (as opposed to other types of traumatic events) and the first within a stepped care approach. In addition, it will provide the first evidence comparing the efficacy of child and family-focused interventions for this target group. Given the significant number of children and adolescents exposed to accidental injury, the successful implementation of this protocol has considerable implications. If efficacious, this early intervention will assist in reducing symptoms of traumatic stress as well as preventing chronic disorder and disability in children experiencing acute PTSD following accidental injury. Trial Registration: Controlled-trials.com: ISRCTN79049138 [ABSTRACT FROM AUTHOR]

Ironic Process Theory and the role of thought suppression have been used in part to explain the phenomenon of intrusive memories in various disorders, including posttraumatic stress disorder. How thought suppression interacts with other cognitive processes believed to be instrumental in the development of traumatic intrusive memory is unclear. In an analogue study, thought suppression and cognitive processing was manipulated in 4 experimental groups after participants (n = 80) viewed a trauma film. The impact of suppression was examined in relation to self-reported intrusive experiences as well as via more objective methods (word stem and dot probe tasks) to assess potential preferential encoding of negative material. Cognitive load appeared to undermine thought suppression ability, with these participants experiencing more intrusions over the week relative to participants in all other conditions. This group also showed greater priming to negative film-related words, and both suppression groups demonstrated enhanced memory for film-related content on recognition testing. Thought suppression mediated the relationship between negative interpretations of initial intrusions and later intrusions experienced over the week. The findings are discussed in the context of ironic process theory and cognitive models of posttraumatic stress. [ABSTRACT FROM AUTHOR]

Objectives. To investigate the impact of social support on both acute stress symptoms and depression in children and adolescents following a single-incident trauma as well as the potential mediating effects of negative appraisals. Design. A cross-sectional concurrent design was used. Method. Ninety-seven children (aged 7-17 years) and a parent of each were recruited through the emergency department or in-patient ward of two metropolitan hospitals. Negative appraisals, child perception of social support, parent availability to provide social support, prior trauma and psychological difficulties, depression and acute stress symptoms were measured within 4 weeks of trauma. Results. Negative appraisals about the trauma were highly correlated with both acute stress and depression symptoms. Social support was negatively correlated with depression symptoms, but not acute stress symptoms. There was a trend for social support to be negatively correlated with negative appraisals. There was no evidence that negative appraisals mediated the social support--symptoms relationships. Conclusions. The findings lend support to recent cognitive and developmental models of the aetiology of post-traumatic stress disorder, and the possible shared cognitive vulnerability between trauma symptoms and depression. Clinically, the results indicate that, appraisals, social support, and depression symptoms should be assessed in addition to trauma symptoms following single-incident traumatic events. The findings also suggest that when depression symptoms are present following trauma exposure, it may be useful to ensure children have adequate social support. Future research should also develop trauma specific measures of social support. [ABSTRACT FROM AUTHOR]

Thompson-Hollands et al.'s (2020) commentary on our systematic review of exposure-based writing therapies for subthreshold and clinical posttraumatic stress symptoms (Dawson et al., 2020) emphasizes important questions about the impact of heterogeneity in drawing inferences from evidence reviews. In this reply, we discuss (a) our rationale for undertaking a systematic review that was broad rather than narrow in scope and (b) provide clarifications on how heterogeneity was considered in the meta-analyses that were conducted. We also strongly agree with Thompson-Hollands et al.'s recommendation that future research should focus on better understanding the mechanisms by which exposure-based writing therapies help reduce posttraumatic stress symptoms. [ABSTRACT FROM AUTHOR]

This research represents the first controlled treatment study of hypnosis and cognitive-behavioral therapy (CBT) of acute stress disorder (ASD). Civilian trauma survivors (N = 87) who met criteria for ASD were randomly allocated to 6 sessions of CBT, CBT combined with hypnosis (CBT-hypnosis), or supportive counseling (SC). CBT comprised exposure, cognitive restructuring, and anxiety management. CBT-hypnosis comprised the CBT components with each imaginal exposure preceded by a hypnotic induction and suggestions to engage fully in the exposure. In terms of treatment completers (n = 69), fewer participants in the CBT and CBT--hypnosis groups met criteria for posttraumatic stress disorder at posttreatment and 6-month follow-up than those in the SC group. CBT-hypnosis resulted in greater reduction in reexperiencing symptoms at posttreatment than CBT. These findings suggest that hypnosis may have use in facilitating the treatment effects of CBT for posttraumatic stress. [ABSTRACT FROM AUTHOR]

The accumulative effect of prior high-magnitude trauma exposure on memory was examined in 73 rape victims, 92% of whom had current posttraumatic stress disorder (PTSD). Participants were administered the Logical Memory component of the Wechsler Memory Scale, the Quick Test to obtain an estimate of intelligence, and were assessed for prior traumatic experiences. Prior exposure to high-magnitude stressors (e.g., child rape, being kidnapped) was significantly correlated with poorer performance on the memory tasks. Regression analyses controlling for estimated IQ and psychopathology severity demonstrated that magnitude of prior trauma exposure predicted performance on the memory task, suggesting that in the current sample, deficits in verbal memory may be related (in part) to the degree of accumulative stress experienced over the lifetime. [ABSTRACT FROM AUTHOR]

Significant proportions of participants drop out of cognitive behaviour therapy for post-traumatic stress disorder (PTSD). This study indexed the pretreatment characteristics of civilian trauma survivors who remained in (n = 95) and dropped out (n = 33) of therapy for chronic PTSD. Therapy involved either cognitive behaviour therapy or supportive counselling. Participants who dropped out of therapy had higher scores on the Impact of Event Scale – Avoidance and the Catastrophic Cognitions Questionnaire, controlling for the influence of pretreatment PTSD severity. These finding suggest that retaining participants in therapy for PTSD may be enhanced by focusing initial therapy attention on modification of catastrophic cognitive styles and avoidance tendencies. [ABSTRACT FROM AUTHOR]

How well children remember negative events is not fully understood. Previous research has failed to simultaneously test memory and perceptions of memory for both negative and positive events. Children (n = 38, 7-17 years) recruited from a hospital following accidental injury were tested for their memory of an injury-producing accident (negative event) and a positive event (unexpectedly receiving a $50 gift voucher). Objective accuracy of memory, memory quality characteristics (e.g., how coherently the event was recalled), children's judgments of their memory (meta-cognitive), and posttraumatic stress (PTS) symptoms were assessed 2 months post-injury. Children's memories for their experiences were verified using witness/parent reports. Memory quality characteristics of children's free recollection were coded with a previously used standardized system. Overall, children showed high levels of accuracy for both events, with little degradation over time. High PTS children showed little evidence of deficits in coherence or organization in their narratives relative to low PTS children. Although in some instances high PTS children judged their memory quality to be poor compared to low PTS children, this depended on how this was assessed (e.g., self-report questionnaire vs. coded narratives). In terms of limitations, it is unclear whether the findings will generalize for memories of repeated events. Witness verification of the accident details itself could be prone to error. In conclusion, the findings are broadly supportive of the proposal made by theorists who argue that trauma memories are recalled no less accurately than other distinctive memories. The role of meta-cognitive elements of children's memory and reporting in PTS is less clear. [ABSTRACT FROM AUTHOR]